440: Dr. Duane Scotti: Gymnastics Medicine

LIVE from the APTA NEXT Conference in Chicago, I welcome Duane Scotti on the show to discuss gymnastics medicine. Dr. Duane Scotti is a physical therapist, educator, researcher and founder of Spark Physical Therapy. He is considered a leader in the fields of rehab, sports medicine, performing arts medicine, and human performance optimization. With years of experience as a physical therapist, runner, and dance instructor in combination with his strength and conditioning background, Duane has been working with many patients to improve all aspects of human performance.

Dr. Duane Scotti is a physical therapist, educator, researcher and founder of Spark Physical Therapy. He is considered a leader in the fields of rehab, sports medicine, performing arts medicine, and human performance optimization. With years of experience as a physical therapist, runner, and dance instructor in combination with his strength and conditioning background, Duane has been working with many patients to improve all aspects of human performance.

Duane is currently the founder of Spark Physical Therapy, providing prehab, rehab, and performance optimization services either onsite or in the comfort of your home within the Cheshire/Wallingford CT region. He also is a clinical assistant professor in the Department of Physical Therapy at Quinnipiac University responsible for coordinating and teaching musculoskeletal examination, intervention, and advanced manual therapy within the orthopedic curriculum.

Duane received his Bachelor of Health Science degree and Master of Physical Therapy degree from Quinnipiac University in 2001 and 2003. He then went on to receive a clinical Doctor of Physical Therapy and a Ph.D. in Physical Therapy from Nova Southeastern University in 2017. Duane is a board-certified Orthopaedic Clinical Specialist, Certified Mulligan Practitioner, certified in dry needling and has advanced training in spinal manipulation, dance medicine, gymnastics medicine, and rehabilitation for runners.

Duane has been in clinical practice working with orthopedic, sports, and performing arts populations since 2003. He has strong clinical and research agendas in screening, injury prevention, and rehabilitation for runners, dancers, and gymnasts. Duane uses an integrative model of manual therapy including manipulation, mobilization, and soft tissue treatment including dry needling and the Graston technique for the management of musculoskeletal dysfunction. Duane is a physical therapy advocate and is actively engaged with the American Physical Therapy Association and serves as Vice President of the Connecticut Physical Therapy Association.

Read the full transcript below:

Karen Litzy: 00:00 Hey everybody. Welcome back to the podcast. I’m coming to you live from Chicago, Illinois at the APTA Next conference. And I have the great pleasure to welcome back to the podcast. Dr. Duane Scotti physical therapists. And today we’re going to be talking about gymnastics medicine. So Duane, welcome back.

Karen Litzy: 00:21 And I have to tell you, gymnastics is something near and dear to my heart. I was a gymnast for many, many years as a child. And luckily I didn’t have any major injuries, but what we’re going to be talking about today are kind of the most common injuries you might see in a gymnast. And this is something that Duane is so passionate about. These are the people he sees. So if you’re a physical therapist out there, and maybe you have the off chance that you might see one of these young athletes, I think this’ll be really helpful for you to give us your insight. So Duane, tell us what are the three most common injuries one might see in a gymnast?

Duane Scotti: 01:02 Well, I think first off is I definitely do have a passion for this area. Like you state because I have a daughter who’s a gymnast. So that is one of the things that I kind of in my career from a clinical standpoint, kind of focused a little bit more in this area is spinning off of like dance medicine and got into the realm of helping gymnasts out because I did see there was a need in the local club in our region. So in terms of the most common injuries I would say, you know, definitely low back pain, in gymnasts and specifically extension based low back pain. So because of all of the kind of back bends you think about, they do like bridges, back walkovers, back handsprings all of those, especially in the young developing gymnast. So usually the smaller ones like the level fours and fives, they’re doing a lot of those skills. A lot of times you’ll tend to see that occur as well as a lot of the compressive loads that happen especially during your floor passes in gymnastics, there’s a lot of compressive loads as well as shear loads that get transmitted to the spine.

Karen Litzy: 02:11 And can you kind of briefly tell us what exactly you mean by when you say a compressive load and can you give an example of when a compressive load might happen and a shear load? Same thing.

Duane Scotti: 02:23 So it’s really the compressive load is if you think of landing, right, so you’re landing, your body weight is coming down. So we know that actually landing, you know, there are some studies that look at between 12 to 17% of your body weight is actually, or times your body weight is actually being loaded through the spine. So that’s that compressive load as opposed to like a shear load, which would be something like if you think of doing that back bend or that bridge where you’re getting one bone kind of shearing on the other. And in the young developing gymnast who is still growing, that can be problematic. And then that’s where we start see things such as stress fractures. So that’s kind of really the most you know, important thing. And the thing that I tried to intervene and educate because a lot of times most gymnasts have the perception that maybe back pain is normal with gymnastics due to the training and it’s going to happen. But being a young gymnast with their bones developing, if they develop that stress fracture that could be detrimental to their long-term health if it goes undiagnosed.

Karen Litzy: 03:28 Oh that was my next question. So let’s talk about differential diagnosis of that stress fracture. Cause I think that’s really important to think about. And I would imagine that a lot of therapists aren’t thinking stress fracture when they’re thinking of a young girl or a young boy. Most of the time we think stress fractures in our older adults with osteoporosis, osteopenia. So how do you differentially diagnosed that stress fracture from other causes of back pain?

Duane Scotti: 03:59 Yeah, so the stress fractures are, they call spondylolysis and it is really diagnosed based upon the history. So kind of taking a report, is that something that typically it can occur acutely from like a specific landing where they felt an acute kind of sudden onset of back pain, but usually it is something that’s developing over time and it’s not getting better with rest and it continues to get worse over time. And then there are some things on the physical exam that we can evaluate whether they have pain usually commonly with extension. So they’re, you know, doing a standing extension test or a stork test standing on one leg, bending back. You can look at the irritability based upon if they have pain with that or if they don’t have pain with like a press up on their stomach, then I feel pretty confident that this person doesn’t have a stress fracture, that it is more muscular.

Duane Scotti: 04:50 But you always have to kind of make sure and rule that out and then looking at confirming that. So you, you know, you send them to a specialist, a spine specialist. It’s not going to show up on x-ray unless it’s chronic by that point that they’ll see the callus formation on x-ray. But it’s really an MRI or a bone scan. And a lot of times, you know, if it is kind of consistent with the history, then even the specialist may not even recommend an MRI just because it’s sometimes not necessary. So sometimes it just requires that kind of protection phase and avoiding the extension based activities. And then that allows that to heal.

Duane Scotti: 05:29 So it’s around, you know, everyone’s different but around six weeks. So that’s the most common timeframe you’ll see. And there are some that recommend bracing. So they call that like the, the Boston braces, the Bob braces where they will brace them. So that athlete is actually preventing any back bending at all. So they’re not going into any extension and forces them. So it’s a hard kind of turtle shell brace. And they’ll wear that for six weeks to really make sure that it heals up. Cause some of these young kids don’t even realize and they don’t understand the severity of it. I actually just had a girl recently who, you know, tried not bracing at first and then wasn’t getting better and now she’s braced and it will allow things to heal.

Karen Litzy: 06:10 Mm, Nice. And my next question was actually going to be how do you communicate this to a young boy, a young girl, young gymnast, that it is of utmost importance to not move into these motions. And then I’m sure you’re reinforcing that with parents, guardians, coaches, etc. So talk to us a little bit about the communication that needs to happen around this. A child with a stress fracture.

Duane Scotti: 06:38 So I’m lucky in the fact that I’m on site, so I have these relationships with the coaches already. So I’m seeing a lot of the gymnast actually within the gym and I have those relationships with the coaches as well as with the patients. I see the parents are always there during the evaluation. After every visit, I’m always communicating, you know, even if they’re not there for the visit, we do the visits in the gym and then I communicate all my findings on each day with them. That being said, it gets challenging, especially during competition season. So this is where the difficulty comes in. And I think it is a very important role we play as healthcare providers where sometimes we have to be the bad guys because we’re looking out for their health. So I had a girl this year before regionals, it was, you know, big competition for her and we have to make that decision and there are tough decisions and if things are sounding and going down that route that you think stress fracture, then it’s like you have to take care of your long-term health.

Duane Scotti: 07:36 And it’s, you know, one of the hardest conversations, honestly, I’ve had, I go, you know, home at night thinking about these decisions. I have these long conversations with their parents and, but in the, you know, in the long run, when I reflect back, I’m like, okay, this was the right decision because you know, I don’t want this, you know, female to have persistent low back pain for the rest of her life and she wants to have kids one day and grandkids and be able to move later in life. So you know, you want to make sure that you’re thinking for their long term health.

Karen Litzy: 08:04 Yeah, I think that’s very well said. And you know, I used to work at the lion king in New York and I remember it was like their last performance at the new Amsterdam theater before they moved to the Minskoff. And one of the young simbas was limping around, limping around. So they brought him in and he was not fit to dance that day. And so I had to make the professional decision to call in stage management, call parents, call tutors, call everyone around this huge production of he can’t go out and dance because I’m looking out for the longterm house. So it is a lot of tears, which I’m sure you can attest to, but you’re right, it’s being a good health care professional. It’s not about just that moment. It’s looking out for these young kids.

Duane Scotti: 08:53 And you know, I definitely pride myself on, you know, getting the recovery for injuries as quick as possible so they can get back out there doing what they love, being able to compete. So when something like that happens, you know, you almost feel like, oh, was I a failure or in, you know, but you have to think about the bigger picture and their long-term health versus that short term gain.

Karen Litzy: 09:14 Yeah. That’s when you take yourself out of it, right. As the therapist, as we should all be doing, we check our ego at the door. It is not us. Sometimes things happen. Timing sometimes sucks and we have to make decisions based on what’s in front of us. And I think if you’re making what you feel is the best decision at the time for the health of that patient, then it’s the right decision. And all right, so outside of stress fractures in the low back, what are there other common types of low back pain? Is it muscular and mechanical, low back pain. And what do you then do for those gymnasts?

Duane Scotti: 09:54 So very good. Mainly there’s not a huge amount of mechanical low back pain that I tend to see when we think of disk related low back pain, sometimes some facet joint. But these kids are a lot younger so it is usually muscular in nature. I kind of see that common pattern, but it is usually due to an underlying instability in the lumbar spine. But honestly more importantly that I’m seeing is the contributing factors. So specifically looking at hip flexibility, so limited hip flexibility specifically the hip flexors, is going to cause more lumbar extension as well as kind of a weakness or inactivation of the glutes. So these girls are doing these leaps and they’re doing these movements where they are extending their hip but they’re really not turning on their glutes and their using, you know, if they do have flexibility issues. So I found, you know, addressing those issues. Number one from a treatment standpoint is going to be helpful in the long run, but also for Prehab standpoint. So in prevention. And that’s what I kind of do in the gym with all these girls is take them through a full screening help to identify those risk factors and then get them on plans to address the soft tissue care because they are doing a lot of strength and conditioning their front of their hips get really tight and that causes that excessive shearing in the lumbar spine.

Karen Litzy: 11:13 Great. So I think for me a big take home here is when you’re looking at these young kids, you’re not, they’re not just tiny adults and so we’re not necessarily looking for disc issues, but rather we really need to look above and below to kind of see, well is the back pain, this muscular back pain a result of compensation from other parts? Right?

Duane Scotti: 11:36 Absolutely. Yes, definitely. And then even the core stability aspects of most of these gymnasts, like super strong, but sometimes there’s still these little muscle imbalances that you can find with like a good examination that they’re not using the muscles you think they’re utilizing. And a lot of, you know, even physicians and you know, these athletes will go to a, you know, a pediatrician or primary care provider or an Ortho and then you’re like, oh well there look at them. They’re Jacked, you know, like you’ve seen gymnasts there, Jacked, like really, really good conditions. Yeah. So they, they’re like, oh, there’s no way they could be weak. But no, like when you actually watch them move and you watch their movement patterns, then you pick up on some of these weaknesses and then you know, having them get into, when they’re doing their extra, it’s like, okay, well where are you feeling this and this. I go, if they’re not feeling they’re glutes at all. They’re like all of their feelings and their hamstrings. So I find a lot of that they’re kind of using your hamstrings to extend their hip joint and not using their glute. So you kind of work on correcting some of those kinds of muscle imbalances.

Karen Litzy: 12:34 Perfect. All right, so let’s move off of low back pain. What’s another common injury that you see in your gymnasts?

Duane Scotti: 12:44 So definitely you know, the most in terms of the research is ankle and foot are kind of the most common region or you know, area to be injured. And most of that is due to traumatic ankle sprains. So they get their classic inversion ankle sprain while they’re beam landing from a pass on the floor, dismount off bars, everything vault like you name it, you know, an ankle sprain can happen. And it usually happens in practice. Not so much in competition. We know that the majority of gymnastics related injuries happen during practice. So I do see a lot of ankle sprains. I do a lot of triaging, especially because I’m onsite. So I need to make that clinical decision on, you know, do we send them out for a radiograph? So utilize the Ottawa ankle rules, and seeing, you know, if they can’t put weight on it, then they’re definitely getting a radiograph. If they’re having pain and they have that bony tenderness, then sending them out for a radiograph. And again, this is where I see us as physical therapists being able to make an impact in our communities in being that point person and make that decision so the athlete goes to the proper place versus just putting ice on it and then going home. And then, you know, so I’ve been able to kind of streamline that process for a lot of the athletes that I see.

Karen Litzy: 13:56 Fabulous. And I don’t think we need to go into the ins and outs of ankle sprain rehab. But have you found amongst this population, what is one thing you can tell another therapist if you do nothing else to rehab these gymnasts after ankle sprain, you must, must, must include this in your program.

Duane Scotti: 14:20 Can I say two things? So first is one thing that I see overlooked a lot is mobility issues. So a lot of people have the assumption that you sprained your ankle, you have a loose ankle and we need just stabilization, stabilization. And that is important. Don’t get me wrong. And kind of proper stabilization going from your balance activities proprioception to plyometrics. Definitely necessary need to do the plyometric training with your gymnast before you release them to do gymnastics training. But also checking for mobility issues, specifically lack of Dorsiflexion during like a weight bearing dorsiflexion test. And I’ve seen that where there’s, you know, asymmetries on both sides and that’s going to be important because when these gymnast land from their floor passes a lot of them, sometimes land short and if they land short, that requires more Dorsi flexion motion. So that can in turn cause you know more limitations of Dorsiflexion, anterior ankle pain. So you really want to make sure you normalize the joint mechanics and the talocrural joint and do your manipulation mobilization techniques to kind of restore that. So that’s one thing. And then, especially if someone’s been immobilized. So if there are mobilized in the walking boot or in an air cast, a lot of times you’ll find stiffness in those joints as well as the distal tibiofibular joint.

Karen Litzy: 15:35 Perfect. Thank you. That is great. I would have thought your firsthand, so we would have been propioception exercises, which are important, but I’m glad that you brought up the mobility stuff. Great. All right, let’s talk about one more common injury that you see in this population.

Duane Scotti: 15:51 So this is more your kind of growth plate injuries. So the kind of growing gymnast as they’re growing, they go through that growth spurt. So commonly in the younger gymnasts, so like the nine 10 year olds, you’re going to see like the Seavers, so they’re going to have heel pain. The calcaneal apophysis and then as they get a little older, usually around 12 ish, you’re going to start to see knee pain. So whether or not it’s Sinding-Larsen-Johansson Syndrome, which is the inferior pole of the Patella or the more common one that everyone knows about osgood schlatters which is at the tibial tubercle. So you will tend to see these kind of growing pains if you will. The big thing is to educate the parents, the gymnast, and there are things that they could be doing at this time.

Duane Scotti: 16:38 They don’t just need to train through pain and usually it relates to soft tissue flexibility. So for Seavers, it’s really the calf, the Achilles, make sure they’re on a good mobility flexibility program for those structures. And then for the knee, a lot of rectus tightness I tend to see, so working on some of the flexibility mobility during this time period and watching load management, so maybe not doing their rigorous training and if they’re going through that kind of gross spurt and they have some pain and now let’s say like summer conditioning starting, then they might need, be able to kind of do a modified practice, especially when it comes to the jumping and the plyometric training. So they’re not doing because we know that’s what really caused it. And that’s why the incidence is so high in gymnast is because they’re going through this rapid growing and they do a lot of jumping, a lot of contraction of the Achilles and contraction of the quads. So that’s why you tend to see pains in both the ankle and the knee area.

Karen Litzy: 17:35 Perfect. Yeah, I had a patient a couple of months ago Seavers disease, she was nine and she was a gymnast. And what was really interesting is I would have her, because I needed to see how she jumped and how she landed. And I don’t know if this contributed to it or not. In my line of thinking, I felt like maybe it did, but when she landed she tended to land in a very valgus position of her knees. And I don’t know, can that, so looking at the biomechanics of the landing, can that help in the treatment of Seavers disease? Cause then we kind of worked on that so that she wasn’t landing in quite such a valgus position. So that in my line of thinking was that if we can help to normalize her landing a little bit more, that she’d be able to more effectively use her calf muscle in order to land instead of being at this very sort of sharp valgus angle.

Duane Scotti: 18:33 Yes. I think that’s definitely important. And then even I guess going one step further than that is looking sagittal plane and with ankle Dorsi flexion. So if they’re limited there because their Achilles is tight and their gastric is tight, I see that even more so. But maybe like you said, if even if they’re weak hip muscles, so your abductors external rotators are weak and they’re going into that dynamic Valgus, you know, could that be a contributing factor to different mechanics going down at the ankle? Possibly.

Karen Litzy: Interesting. Yeah. There’s so much to think about with these gymnast’s that you would not think about in your ordinary population.

Duane Scotti: Right, right. No, absolutely. And it is as you said that they have such high levels of training, you know, the girls I see, you know, once they get up to level six and above, they’re in the gym for 24, you know, 25 hours a week.

Duane Scotti: 19:21 So it’s a lot of training. The only get like two weeks off a year. So it’s like at the end of the season befor summer starts and then before a fall starts. So it’s a lot of training, a lot of wear and tear on their bodies. And that’s why it’s so important to be able to pick up on, you know, contributing factors. Cause every gymnast is different too. So someone’s going to have maybe a tightness in the front of their hips. Someone’s gonna have some tight calves, so I’m just going to have maybe week shoulder muscles and they’re starting to get shoulder pain with bars or tight lats. So that’s a common thing where they’re limited with overhead mobility with reaching. So you kind of need to identify what each one does. And that’s what I like to do is to get them on like a customized kind of program and it’s like, okay, here are your like top five exercises you should be doing before practice every single day.

Duane Scotti: 20:03 So as opposed to just like chatting with your friends, like, let’s prime the body, let’s get, you know, warmed up. If it’s rolling the front of your hips, doing some glute activation exercises, make sure they’re turned on before practice starts. That’s what they need to be doing.

Karen Litzy: And you know, I was just going to ask you, what advice would you give to, let’s say, any physical therapists out there listening to healthcare practitioner who maybe doesn’t have the amount of experience you have with the gymnastic population, but like I said, maybe they’ve got a gymnast coming in and I feel like you just kinda answered that. Do you want to add anything to it? What advice you would give to that PT?

Duane Scotti: 20:48 Don’t be afraid to reach out and talk with the coaches. I think a lot of the gymnastics world and culture, I tend to see a little bit of kind of medical professionals on one side, coaches on the other. The coaches think that the medical professionals don’t understand their sport and vice versa. The medical professionals think that the sport is just bad for them and they shouldn’t be doing it almost that it’s too much and it’s not good for their bodies. So I think we need to kind of meet in the middle and actually communicate and have these conversations and you know, try to meet in the middle. And that’s what I tend to do with the coaches and cause they, I could see where their mindset is. And I, you know, with my years of experience coming from the kind of clinical mindset and injury side, and I’ve shifted a little bit in some of my thought processes as well. Being able to actually be on site and see some of the training that they do and to see some of the practices.

Duane Scotti: 21:32 So just don’t be afraid to communicate and I guess reach across the aisle and be able to say, okay, this is what I’m finding, and even just letting them know that, hey, this is pretty irritable right now, but it’s a minor problem, but if she can do a modified practice today and tomorrow and then she has off on Sunday, that will give her three days of this kind of protected rest phase and the next week she’ll be able to do full practices to have you kind of frame it like that. Then the coaches are like, okay, I could, I could deal with that. Versus the coaches being like, no, they can’t modify practice right now. We have a competition in two weeks. But if you’ve kind of framed it that way and say like, Hey, if we just allow these couple of days and then next week they’re going to be able to have full practice without limiting themselves at all, then they’re more likely to kind of go with your recommendations versus, you know, everyone being on kind of different sides.

Karen Litzy: 22:20 Perfect. I think that’s great advice. Communication is vital and everything we do with our patients from all the different stakeholders that are involved to the patient themselves, to parents and caregivers and to each other. So I think that’s great advice. Thank you so much. And I have one last question for you and it’s the one that I ask everyone and that’s knowing where you are now in your life and in your practice. What advice would you give to yourself as a new Grad right out of physical therapy school?

Duane Scotti: 22:51 So this is a tough question because I hear this all the time because I listened to all your podcasts and you would think I would have the answer right off the top of my head. But I would probably say, there’s a couple things is one, just not be afraid to fail. Failure is good because we learn from that and then don’t abandon certain techniques or philosophies early on if you’re not getting it right. Continue to learn and grow, evolve. And that’s how we all get better in what we do.

Karen Litzy: 23:22 I think that’s wonderful advice. That’s perfect. Resonates with me. Very much so. Thank you, Duane, for coming back on the podcast again and educating us all around gymnastics medicine, so thank you.

Duane Scotti: 23:32 Awesome. Thank you for having me. This has been great.

Karen Litzy: 23:35 My pleasure. And everyone out there listening. Thanks so much. Have a great couple of days and stay healthy, wealthy, and smart.

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